assessment of chest ,thorax of children.

Content: inspection of skin, examination of breast, inspection,palpation ,percussion and auscultation of thorax

1. ASSESSMENT OF CHEST / THORAX AND THORACIC ORGANS. PRESENTED TO PRESENTED BY ESTEEMED ZARIFA MAAM MEHVISH IQBAL ASSISTANT PROFESSOR MSC(N) 1 ST YEAR MMINSR SKIMS PEDIATRIC NURSING

2. CONTENT INSPECTION OF SKIN EXAMINATION OF BREASTS INPECTION , PALPATION OF THORAX PALPATION , PERCUSSION AND AUSCULTATION OF THORACIC ORGANS

3. INSPECTION OF SKIN: Bottle or pacifier may calm child. Use of prewarmed stethoscope . While baby is quiet examine uncovered chest for respiratory movements , presence of cyanosis , noisy respiration . Examine Nipple location i.e between 4 th and 5 th ribs and slightly lateral to midclavicular line , color ,spacing , presence of secretions , fissures or other abnormalities . Supernumery nipples may be considered normal.

4. EXAMINATION OF BREASTS : Breast contain 15-20 glandular tissue lobes and 15-20 openings of lactiferous ducts , areola 1-2cm ( montgomery glands) with smooth muscle fibres which under stimulation cause nipple to erect. Breast examination of girls after menstrual period so that premenstrual tenderness and engorgement will not be misleading. In good light child sits facing nurse ; contour symmetry of 2 breasts , nipple, areolar tissue compared . Also teaching self breast examination and knowledge of fibroadenomas . Supraclavicular and axillary lymph nodes palpated for any deviation.

5. LYMPH NODE ASSESSSMENT

6. THORAX

7. DEFORMITIES IN BONES OF CHEST During infancy chest is round , as child grows lateral diameter becomes more than AP diameter. Chicken or pigeon breast( pectus carinatum ) :rickets , marfan syndrome or chronic upper respiratory obstructions. Funnel chest ( pectus excavatum ) :may be normal or rickets or marfan syndrome. Barrel chest : chronic lung problems like asthma, cystic fibrosis Harrison’s groove: rickets , chronic respiratory problem.

8. DEFORMITIES OF THROCIC SPINE

9. PALPATION Inspiration : chest wall expands , sternal angle increases , diaphragm is lowered. Expiration: chest cavity decreases in size , sternal angle decreases , diaphragm is elevated Ribs are palpated to determine absence or presence of tenderness. Chest palpated for tumors , cysts , or other growths. Clavicular and axillary areas are assessed for enlarged lymph nodes. 2 sets of lymph nodes (parietal and visceral set) Placement of hands to observe expansion and symmetry of chest wall movements and fremitus : If respiratory movements are not symmetrical following may be diagnosed: an obstructing foreign body , pneumonia , pneumothorax , atelactasis .

10. TYPES OF RESPIRATION : EUPNEA: normal quiet effortless respiration. TACHYPNEA: rapid rate. Seen in fever, infection, anxiety, heart failure, certain poisoning. BRADYPNEA: slow rate. Seen in brain tumor and opiates poisoning. APNEA: temporary cessation of respiration. May be normal in neonates but if persists need to investigate HYPERPNEA: increased rate and depth of respiration. Seen in metabolic acidosis. Also called kussmaul respiration. ALKALOTIC RESPIRATIONS: slow shallow respiration. Seen in alkalosis .

11. *DYSPNEA: difficulty breathing. Seen in obstruction of airway , asthma. *CHEYNE-STROKES RESPIRATION: respirations increased in force and frequency to certain point and then decrease until they cease altogether. Seen in heart failure and stroke. *BIOTS RESPIRATIONS: irregular periods of apnea alternating with periods in which 4 or 5 breaths of identical depth are taken. Seen in increased intracranial pressure .

12. PERCUSSION Chest sounds elicited on percussion: Resonance: all lobes of lung not near other organs Liver dullness: liver lying over lung . Downward from 4 th or 5 th interspace on right side in midclavicular line. Flat : end of lung and near liver Cardiac dullness: due to heart. Left boarder of sternum from 2 nd to the 5 th interspace and to the midclavicular . Tympany : stomach filled with air. Left side below 5 th or 6 th interspace

13. AUSCULTATION Purpose : assess breath sounds for location, duration, pitch, intensity and quality, the condition of lung, and pleural space , presence of mucus ,fluid or obstruction in tracheobronchial tree. Types of breath sound : TUBULAR/BRONCHIAL: present normally over trachea near suprasternal notch. VESICULAR: present over lung tissue BRONCHOVESICULAR: present near bronchi (below clavicle and upper intrascapular area). Decreased breath sounds : early stage of pneumonia , pneumothorax , pleural effusion , emphysema , or atelactasis . Exaggerated vesicular sounds : TB, emphysema, later stage of pneumonia. Bronchial breath sounds other than trachea indicate atelactasis Breath sounds that are heard over bone such as sternum may be due to consolidation or foreign body or mass.

14. ADVENTITIOUS SOUNDS :

15. ABNORMAL TYPE OF BREATHING Amphoric breathing: low pitched hollow sound can indicate phemothorax or compression of lung from effusion Cogwheel respiration(interrupted respiration): produce peculiar jerky inspiration. The expiratory and inspiratory sounds are not continuous but split into 2 or more separate sounds. Bronchophony : heard over healthy bronchus.This sound heard elsewhere indicate solidification of lung tissue. Whispered pectoriloquy : transmission of sound of whispered words through walls of chest and heard with stethoscope. Egophony : Child’s ‘ eeee ’ through stethoscope heard as ‘ay’.

16. HEART

17. INSPECTION AND PALPATION OF HEART . Heart inspection is a visual examination of patient that can provide clues to their cardiac condition e.g skin for temperature, nails for splinter hemorrhages, extremities for dependent edema , etc Palpation include assessing arterial pulse , measuring BP, palpating any thrills in chest . PERCUSSION OF HEART: Percussion outlines borders of heart and determines any displacement or enlargement. Difficult in infants because of barrel chest and thick layer of subcutaneous fat of chest wall.

18. SITES OF ASSESSING HEART SOUNDS.

19. EVALUATIION OF HEART SOUNDS: * Rate *INTENSITY: S1 is normally more intense than S2 at apex. The intensity of S2 is greater at base of heart than is S1. *RHYTHM: normal rhythm is regular with same interval between each beat. *QUALITY: each normal heart sound should be distinct and clear. PATTERNS OF HEART SOUNDS: *BRADYCARDIA: decreased heart rate. It is rare in children upto adolescent period. During adolescent period, especially in atheletic boys heart rate may drop as low as 40 beats per min. such adolescents have effective and well developed cardiac musculature.

20. * TACHYCARDIA: increased heart rate over 200 in neonates, 150 in infants and 120 in older children. *ALTERNATING PULSE ( pulsus alternans ): a strong beat followed by a weak beat . *INTERMITTENT PULSE: one in which various beats are dropped. *IRREGULAR PULSE: one in which beats occur at irregular interval. *PLATEAU PULSE: one that rises slowly and is sustained as in a prolonged peak causing a plateau. *PARADOXIC PULSE: pulse that decreases in intensity or become smaller during inspiration. *THREADY PULSE: one that is fine and barely perceptile that appears and disappears.

21. *CORRIGAN OR WATER HAMMER PULSE: a very forceful bounding beat . seen in PDA and aortic insufficiency. *SINUS ARRHYTHMIA: in this heart rate becomes more rapid during inspiration and slows on expiration. *BIGEMINY: 2 beats come together in rapid succession in pairs because of a premature beat. This occurs in normal condition but may also indicate organic heart disease. *ATRIAL FIBRILLATION: characterized by irregular convulsive movements of atria of the heart. *VENTRICULAR FIBRILLATION: fatal. Characterized by twitching of ventricular muscle. *MURMERS: Caused by the back and forth flow of blood in the heart and major arteries. Grade 1 very soft and faint and grade 6 bei ng very loud heard without stethoscope.

22. REFERENCES: Dorothy R morlow Barbara A Redding testbook of pediatric nursing sixth edition page no. 119-131. www.google.com .